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Palermo M, Santonocito S, Failla G, Vacirca F, Venturini M, Palmucci S, Basile A. Bleeding duodenal varices urgently treated with TIPS and coil embolization in a patient with cirrhosis: A rare case. Radiol Case Rep 2021; 16:1580-1585. [PMID: 33995748 PMCID: PMC8093421 DOI: 10.1016/j.radcr.2021.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/25/2022] Open
Abstract
Duodenal varices are ectopic varices that can cause severe and life-threatening gastrointestinal bleeding. Diagnosis and treatment of ectopic varices is challenging, because endoscopy is often unproductive in detecting and treating ectopic varices. Interventional radiology appears as an alternative in this setting, thanks to its important role in treating the bleeding caused by ectopic varices and in preventing rebleedings. We present an interesting case of bleeding ectopic varices in a male 62-years-old cirrhotic patient (Child-Pugh B8). The patient presented with hemorrhagic shock caused by massive melena. CT angiography showed intraluminal blood and identified the source of bleeding as an ectopic varicose vein draining into the superior mesenteric vein. Interventional radiology approach was the only applicable one to reach and effectively treat the source and cause of bleeding by TIPS placement and embolization of the collateral feeding at the same session
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Affiliation(s)
- Monica Palermo
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
| | - Serafino Santonocito
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
| | - Giovanni Failla
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
| | - Francesco Vacirca
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Stefano Palmucci
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
| | - Antonio Basile
- Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia," University-Hospital Policlinico "G. Rodolico-S. Marco", University of Catania, Via S. Sofia, 95126, Catania, Italy
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Lee A, Suhardja TS, Nguyen TC, Chouhan HS. Management options for rectal variceal bleeding in the setting of hepatic encephalopathy. ANZ J Surg 2020; 91:49-54. [PMID: 32407000 DOI: 10.1111/ans.15982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022]
Abstract
Bleeding related to rectal varices associated with portal hypertension is rare but life-threatening, and requires prompt treatment. We reviewed the literature for patients with this complex presentation and current recommendations, and commented on a case at our institution of a 68-year-old man with Child-Pugh B alcoholic liver cirrhosis and hepatic encephalopathy who presented with profuse life-threatening rectal variceal bleeding. Treatment options for rectal varices in patients with hepatic encephalopathy were reviewed and a management algorithm was devised from current knowledge in the literature. We suggest endoscopic management, and if unsuccessful then to proceed to angioembolization and/or balloon-occluded retrograde transvenous obliteration, which may be used in conjunction with surgical management. The chosen therapeutic option may depend on the clinical condition of the patient, the cause of portal hypertension and clinical expertise or facilities available. Given that transjugular intra-hepatic portosystemic shunting is contraindicated in patients with hepatic encephalopathy, management of life-threatening rectal variceal bleeding should be multimodal.
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Affiliation(s)
- Alice Lee
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Thomas Surya Suhardja
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Thang Chien Nguyen
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Hanumant S Chouhan
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Melbourne, Victoria, Australia
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Abstract
Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.
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Abdel-Aal AK, Dawoud N, Moustafa AS, Hamed MF, Saddekni S. Percutaneous Transhepatic Embolization of Bleeding Rectal Varices Using A New Embolic And Sclerotic Mixture Augmented By Amplatzer Vascular Plug 2. J Radiol Case Rep 2016; 10:44-51. [PMID: 27761198 PMCID: PMC5065273 DOI: 10.3941/jrcr.v10i9.2580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report a case of 59-year-old female with non-alcoholic-steato-hepatitis (NASH) induced cirrhosis, who presented with hematochezia. The patient had a history of bleeding esophageal varices treated with endoscopic variceal ligation (EVL). Colonoscopy showed large rectal varices which were the source of her lower gastrointestinal bleeding (LGIB). Since endoscopic treatment for LGIB are limited, and because the patient had portal vein thrombosis which contraindicated transjugular intrahepatic portosystemic shunt (TIPS), we performed percutaneous transhepatic embolization of her rectal varices using a new mixture of embolic and sclerotic agents, followed by Amplatzer plug 2 (AVP 2). To our knowledge, the use of this new mixture with the AVP 2 in the rectal varices treatment has not been previously published in literature. Our case provides an alternative treatment modality that can be used for rectal varices treatment, when TIPS and endoscopic management fails or is contraindicated.
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Affiliation(s)
- Ahmed Kamel Abdel-Aal
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Cairo University, Cairo, Egypt
| | - Nabila Dawoud
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Amr Soliman Moustafa
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Zagazig University, Zagazig, Egypt
| | - Maysoon F Hamed
- Department of Family medicine, University of Alabama, Tuscaloosa, Alabama, USA
| | - Souheil Saddekni
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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Al Khalloufi K, Laiyemo AO. Management of rectal varices in portal hypertension. World J Hepatol 2015; 7:2992-2998. [PMID: 26730278 PMCID: PMC4691702 DOI: 10.4254/wjh.v7.i30.2992] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/13/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.
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Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol 2015; 7:1601-1605. [PMID: 26140080 PMCID: PMC4483542 DOI: 10.4254/wjh.v7.i12.1601] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/21/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Ectopic varices are unusual with portal hypertension and can involve any site along the digestive tract outside the gastroesophageal region. Hemorrhage from ectopic varices generally are massive and life threatening. Diagnosis of ectopic varices is difficult and subsequent treatment is also difficult; the optimal treatment has not been established. Recently, interventional radiology and endoscopic treatments have been carried out successfully for hemorrhage from ectopic varices.
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Yoshino K, Imai Y, Nakazawa M, Chikayama T, Ando S, Sugawara K, Hamaoka K, Inao M, Oka M, Mochida S. Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis. Hepatol Res 2014; 44:1088-94. [PMID: 24033909 DOI: 10.1111/hepr.12232] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/21/2013] [Accepted: 08/27/2013] [Indexed: 01/09/2023]
Abstract
AIM Although rupture of rectal varices is rarely encountered, it may provoke massive and fatal hemorrhage in patients with liver cirrhosis. We examined the clinical features of patients showing bleeding from rectal varices to establish a suitable therapeutic strategy for the lesions. METHODS Twelve cirrhotic patients with bleeding rectal varices were enrolled. Surgical suture, endoscopic variceal ligation (EVL) or balloon tamponade was performed to achieve the initial hemostasis. Then, the feeding and drainage vessels of the varices were evaluated by computed tomography, and additional procedures were undertaken: EVL was performed when the sizes of the varices and feeding vessels were small. In contrast, in patients with varices of large sizes, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed when single or two drainage vessels were identified, while endoscopic injection sclerotherapy (EIS) using ethanolamine oleate was carried out for varices with three or more drainage vessels. RESULTS The Child-Pugh class was grade A in four, B in six and C in two patients. Eleven patients had received previous therapy for esophageal varices. Initial hemostasis was achieved by surgical suture in three patients, EVL in one patient and balloon tamponade in two patients. EVL, EIS and B-RTO were carried out as additional procedures in seven, three and one patient, respectively. Rebleeding from the rectal varices occurred in only one patient who underwent EVL as an additional procedure. CONCLUSION Bleeding from rectal varices was controlled satisfactorily by the therapeutic strategy of selecting EVL, EIS or B-RTO as an additional therapy according to the size and hemodynamics of the varices.
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Affiliation(s)
- Kiyoko Yoshino
- Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Iruma-gun, Japan
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Abstract
Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.
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Affiliation(s)
- Nathalie H. Urrunaga
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 22 S. Greene Street, N3W156, Baltimore, MD 21201, USA
| | - Don C. Rockey
- Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC 29425, USA,Corresponding author.
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Treatment of bleeding rectal varices with transumbilical venous obliteration of the inferior mesenteric vein. Surg Laparosc Endosc Percutan Tech 2014; 23:e134-7. [PMID: 23752023 DOI: 10.1097/sle.0b013e31828031ec] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 56-year-old male with alcohol-induced liver cirrhosis developed rectal varices. He had a prior history of treatment for esophageal varices with endoscopic variceal ligation. Despite the repeated treatment for rectal varices with endoscopic variceal ligation, endoscopic injection sclerotherapy, and surgery, the bleeding from the rectal varices could not be controlled. Multidetector-row computed tomography and 3D-angiography revealed the hemodynamic profile of the rectal varices. We next approached the rectal varices through the umbilical vein on the abdominal wall, and successfully embolized the varices continuing from the inferior mesenteric vein using coils and a 5% solution of ethanolamine oleate with iopamidol.
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Maslekar S, Toh EW, Adair R, Bate JP, Botterill I. Systematic review of anorectal varices. Colorectal Dis 2013; 15:e702-10. [PMID: 24020839 DOI: 10.1111/codi.12417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 06/18/2013] [Indexed: 12/13/2022]
Abstract
AIM Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise. METHOD A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices. RESULTS Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure. CONCLUSION As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.
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Affiliation(s)
- S Maslekar
- The John Goligher Colorectal Unit, St James's University Hospital, Leeds, UK
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12
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Moore JS, Seah AS, Hyman N. Management of hemorrhoids in unusual circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Bach HH, Wang N, Eberhardt JM. Common anorectal disorders for the intensive care physician. J Intensive Care Med 2013; 29:334-41. [PMID: 23753241 DOI: 10.1177/0885066613485347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.
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Affiliation(s)
- Harold H Bach
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA Department of Molecular Pharmacology and Therapeutics, Loyola University Medical Center, Maywood, IL, USA
| | - Norby Wang
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Joshua M Eberhardt
- Division of Colon and Rectal Surgery, Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
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Almadi MA, Almessabi A, Wong P, Ghali PM, Barkun A. Ectopic varices. Gastrointest Endosc 2011; 74:380-8. [PMID: 21612777 DOI: 10.1016/j.gie.2011.03.1177] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 03/14/2011] [Indexed: 12/13/2022]
Affiliation(s)
- Majid Abdulrahman Almadi
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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Sato T, Yamazaki K, Akaike J, Toyota J, Karino Y, Ohmura T. Retrospective analysis of endoscopic injection sclerotherapy for rectal varices compared with band ligation. Clin Exp Gastroenterol 2010; 3:159-63. [PMID: 21694861 PMCID: PMC3108668 DOI: 10.2147/ceg.s15401] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND AIMS The study's aim was to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) compared with endoscopic band ligation (EBL) in treating rectal varices. METHODS Data from 34 consecutive patients who underwent endoscopic treatments for rectal varices were analyzed. The clinical outcomes, including complications, related to EIS or EBL retrospectively. RESULTS In 25 of the 34 patients, EIS was performed weekly 2-5 times (mean, 2.7), and the total amount of sclerosant ranged from 3.2 to 12.0 mL (mean, 5.2 mL). After EIS, colonoscopy revealed shrinkage of the rectal varices in all 25 patients, with no complications reported. In 9 of the 34 patients, EBL was performed weekly 1-3 times (mean, 2.2), and bands were placed on the varices at 2-12 sites (mean, 8.0). After EBL, colonoscopy revealed ulcers and shrinkage of the rectal varices in all nine patients, eight of whom experienced no operative complications. The overall recurrence rate for rectal varices was 10 of 24 (41.7%), including 5 of 9 (55.6%) receiving EBL and 5 of 15 (33.3%) receiving EIS, over a 1-year follow-up period (n = 24). All four patients with recurrence of bleeding were EBL cases, versus no EIS cases (P < 0.05). CONCLUSION EIS appears superior to EBL with regard to effectiveness and complications after endoscopic treatment of rectal varices.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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Bommana V, Shah P, Kometa M, Narwal R, Sharma P. A Case of Isolated Duodenal Varices Secondary to Chronic Pancreatitis with Review of Literature. Gastroenterology Res 2010; 3:281-286. [PMID: 27942309 PMCID: PMC5139857 DOI: 10.4021/gr249w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2010] [Indexed: 12/13/2022] Open
Abstract
An unusual case of upper gastrointestinal hemorrhage due to an isolated varix involving the 2nd part of the duodenum is presented here. The varix was the result of Chronic Pancreatitis induced the superior mesenteric vein obstruction. The diagnosis was made preoperatively by upper gastrointestinal endoscopy and selective mesenteric angiogram. Patient was treated successfully with Mesocaval shunt surgery between the superior mesenteric vein and the inferior vena cava using a 10 mm Dacron graft. This is the unique case showing hemorrhagic complication of Chronic Pancreatitis due to the superior mesenteric vein obstruction.
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Affiliation(s)
- Venugopala Bommana
- St. Vincent Mercy Medical Center, Toledo, Ohio, 2213 Cherry Street, Toledo, Ohio 43608, USA
| | - Prasun Shah
- St. Vincent Charity Hospital, Cleveland, Ohio, 2351 East 22nd Street, Cleveland, OH 44115, USA
| | - Michael Kometa
- St. Vincent Mercy Medical Center, Toledo, Ohio, 2213 Cherry Street, Toledo, Ohio 43608, USA
| | - Rawan Narwal
- St. Vincent Mercy Medical Center, Toledo, Ohio, 2213 Cherry Street, Toledo, Ohio 43608, USA
| | - Prashant Sharma
- St. Vincent Mercy Medical Center, Toledo, Ohio, 2213 Cherry Street, Toledo, Ohio 43608, USA
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18
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Transverse colonic varices successfully treated with endoscopic procedure. Clin J Gastroenterol 2008; 1:52-55. [PMID: 26193462 DOI: 10.1007/s12328-008-0010-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 03/03/2008] [Indexed: 01/27/2023]
Abstract
A 75-year-old woman with hepatitis C virus antibody-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed red color-positive tortuous transverse colonic varices near the splenic flexure. Colonic varices were considered to be the most probable cause of bleeding, although the precise site could not be determined. Endoscopic injection sclerotherapy was performed for colonic varices. Endoscopic clipping was performed for bilateral sites of varices as an additional treatment. Four months after endoscopic treatments, colonoscopy revealed ulcer scars in the transverse colon and shrinkage of the varices.
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Abstract
Acute bleeding from the colon and rectum is less frequent and less dramatic than haemorrhage from the upper gastrointestinal tract. In most cases, bleeding from the colon and rectum is self-limiting and requires no specific therapy. Diverticula and angiectasias are the most frequent sources of bleeding. Malignancy, colitis (inflammatory bowel disease, non-steroidal anti-inflammatory drugs, and infectious colitis), ischaemia, anorectal disorders, postpolypectomy bleeding, and HIV-related problems are less frequent causes. The recurrence rate, especially in diverticular bleeding, is high. Resuscitation and haemodynamic stabilisation of the patient is the first step in the management of colonic bleeding. Urgent colonoscopy is the method of choice for diagnosis and therapy. By analogy with peptic ulcer bleeding, risk stratification using stigmata of haemorrhage is gaining more importance. Modern endoscopic techniques such as injection therapy, thermocoagulation and mechanical devices seem to be effective in achieving haemostasis and avoiding precarious surgery. Angiography and nuclear scintigraphy are reserved for those patients in whom colonoscopy is not possible or has repeatedly failed to localise the bleeding site.
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Affiliation(s)
- J Barnert
- III. Medizinische Klinik, Klinikum Augsburg, Postfach 101920, D-86009 Augsburg, Germany
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20
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Boursier J, Oberti F, Reaud S, Person B, Maurin A, Cales P. [Bleeding from rectal varices in a patient with severe decompensated cirrhosis: success of endoscopic band ligation. A case report and review of the literature]. ACTA ACUST UNITED AC 2006; 30:783-5. [PMID: 16801904 DOI: 10.1016/s0399-8320(06)73315-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In patients with cirrhosis, portal hypertension can be complicated by bleeding rectal varices. Treatment of bleeding rectal varices is not well established because clinical therapeutic trials are scarce in the literature and there are only a few case reports. In most cases, first line treatment is endoscopic (band ligation or sclerotherapy) and in case of failure or rebleeding, portosystemic shunts are the second line treatment. The indication of endoscopic treatment is not always easy in patients with cirrhosis and impaired liver function as well as major haemostatic problems. We report the case of a patient with severe decompensated cirrhosis and bleeding rectal varices who was successfully treated by endoscopic band ligation.
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Affiliation(s)
- Jérôme Boursier
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire, Angers
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Vidal V, Joly L, Perreault P, Bouchard L, Lafortune M, Pomier-Layrargues G. Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol 2006; 29:216-9. [PMID: 16284702 DOI: 10.1007/s00270-004-0346-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices. METHODS From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1). RESULTS TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 +/- 5.4 to 6.4 +/- 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), self-limited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One- and 2-year survival rates were 80% and 76%, respectively. CONCLUSION The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.
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Affiliation(s)
- V Vidal
- Department of Radiology, CHUM - Saint-Luc Hospital, 1058, Saint-Denis Street, Montréal, QC, H2X 3J4, Canada
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Sato T, Yamazaki K, Akaike J. Evaluation of the hemodynamics of rectal varices by endoscopic ultrasonography. J Gastroenterol 2006; 41:588-92. [PMID: 16868808 DOI: 10.1007/s00535-006-1815-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Accepted: 03/14/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND The usefulness of endoscopic color Doppler ultrasonography (ECDUS) for evaluating hemodynamics is examined in 12 cases of rectal varices. We also evaluate the safety of endoscopic therapies in rectal variceal patients. METHODS ECDUS was performed for 12 rectal variceal patients with a 7.5-MHz convex-type Pentax FG-32UA system. A Hitachi EUB 525 was used for the display. ECDUS provides a color display of blood flow, and calculates the velocity using a fast-Fourier transform analysis. We monitored the color flow images and measured blood flow velocity in rectal varices. Then, we evaluated the velocity of 350 F2-type esophageal varices via ECDUS, and compared the velocities between rectal varices and esophageal varices. RESULTS Color flow images of rectal varices and of inflow vessels to rectal varices were obtained in all 12 patients with ECDUS. The mean velocity of F2-type rectal varices was 5.5 +/- 1.3 cm/s (n = 12), while the mean velocity of F2 esophageal varices was 8.4 +/- 3.1 cm/s (range, 4.5-12.5 cm/s) (n = 350) via ECDUS. The velocities in rectal varices were lower than those in esophageal varices. Endoscopic injection sclerotherapy (EIS) was successfully performed in five red-color-sign-positive rectal variceal patients having a mean velocity 5.4 +/- 1.1 cm/s. CONCLUSIONS The velocities of rectal varices were lower than those of esophageal varices. Evaluation of the hemodynamics of rectal varices is important for determining the appropriate therapeutic option. EIS is an effective therapy in cases of slow variceal flow. ECDUS is a necessary tool for effective and safe EIS for rectal varices.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Sapporo, 060-0033, Japan
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23
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24
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Parvaiz A, Azeem S, Singh RK, Lamparelli M. Stapled hemorrhoidopexy: an alternative technique for the treatment of bleeding anorectal varices. Report of a case. Dis Colon Rectum 2006; 49:411-2. [PMID: 16322963 DOI: 10.1007/s10350-005-0255-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Amjad Parvaiz
- Department of Surgery, Dorset County Hospital, Williams Avenue, Dorchester, DTI 2JY, United Kingdom
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25
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Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, Burroughs AK. Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 2004; 41:560-6. [PMID: 15464235 DOI: 10.1016/j.jhep.2004.06.024] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2004] [Revised: 05/30/2004] [Accepted: 06/25/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS). METHODS We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5). RESULTS TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding. CONCLUSIONS Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.
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Affiliation(s)
- Marcello Vangeli
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital and NHS Hampstead Trust, London, UK
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26
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Obideen MK, Wehbi M, Ghazale A, Martinez E, Cai Q. Efficacy and safety of transjugular intrahepatic portosystemic shunt in the treatment of nongastric extraesophageal variceal bleeding. J Clin Gastroenterol 2004; 38:373-6. [PMID: 15087699 DOI: 10.1097/00004836-200404000-00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Although esophageal varices are the most common site of variceal bleeding, extraesophageal varices cause up to 30% of variceal bleeding. Unlike esophageal variceal bleeding, the experience in management of extraesophageal variceal bleeding, especially nongastric extraesophageal variceal bleeding is limited, and there are no established guidelines for treatment of nongastric extraesophageal variceal bleeding. This study aims to provide experience in treatment of nongastric extraesophageal variceal bleeding with transjugular intrahepatic portosystemic shunt in a tertiary medical center. METHODS We retrospectively reviewed all cases, admitted or transferred to Emory University Hospital, with extraesophageal variceal bleeding who had transjugular intrahepatic portosystemic shunt as the final resolution to control bleeding over a period of 4 years, from January 1999 to January 2003. We also compared the outcomes after transjugular intrahepatic portosystemic shunt for bleeding from gastric varices and nongastric extraesophageal varices. RESULTS Forty-one patients (33 gastric varices and 8 nongastric extraesophageal varices) with extraesophageal variceal bleeding who had transjugular intrahepatic portosystemic shunt performed were identified in this study period. Bleeding was controlled immediately in 90% (37/41) of those patients. The mortality was 7% (3/41). The rebleeding rate was 10% (4/41). Encephalopathy occurred in 24% (10/41) of the patients. Patients with gastric varices bleeding appeared to have more advanced liver disease than patients with nongastric extraesophageal varices bleeding. The outcomes after transjugular intrahepatic portosystemic shunt for bleeding from gastric varices and nongastric extraesophageal varices were similar. CONCLUSIONS Transjugular intrahepatic portosystemic shunt is an effective and safe treatment of extraesophageal variceal bleeding, including bleeding from gastric varices and nongastric extraesophageal varices.
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Affiliation(s)
- M Kamil Obideen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA
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Silvain C. [How to prevent and to treat bleeding from gastric or ectopic or from portal hypertension gastropathy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B218-26. [PMID: 15150516 DOI: 10.1016/s0399-8320(04)95259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Christine Silvain
- Service d'Hépato-Gastroentérologie et Assistance Nutritive, CHU La Milétrie, 86021 Poitiers Cedex
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28
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Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
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Affiliation(s)
- Babak Firoozi
- Division of Gastroenterology, VA New York Harbor Healthcare System, Bellvue Hospital, NYU School of Medicine, New York 10010, USA
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30
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Hidajat N, Stobbe H, Hosten N, Schroeder RJ, Fauth M, Vogl T, Felix R. Transjugular intrahepatic portosystemic shunt and transjugular embolization of bleeding rectal varices in portal hypertension. AJR Am J Roentgenol 2002; 178:362-3. [PMID: 11804893 DOI: 10.2214/ajr.178.2.1780362] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Nico Hidajat
- Department of Radiology, Charité, Virchow Clinic of the Humboldt University, Augustenburger Platz 1,13353 Berlin, Germany
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Ikeda K, Konishi Y, Nakamura T, Nabeshima M, Yamamoto S, Migihashi R, Chiba T. Rectal varices successfully treated by endoscopic injection sclerotherapy after careful hemodynamic evaluation: a case report. Gastrointest Endosc 2001; 54:788-91. [PMID: 11726865 DOI: 10.1067/mge.2001.119258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- K Ikeda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Postgraduate School Of Medicine Kyoto University, Kyoto, Japan
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Malki S, Allen R, Pavli P. Transjugular intrahepatic portosystemic shunt for intractable colonic bleeding in a patient with cirrhosis. J Gastroenterol Hepatol 2000; 15:962-3. [PMID: 11022842 DOI: 10.1046/j.1440-1746.2000.02197.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
A patient with portal hypertension due to alcoholic liver disease developed colonic bleeding that responded to transjugular intrahepatic portosystemic shunt (TIPS) after the failure of other measures. This case illustrates that TIPS should be considered in the treatment of colonic, as well as upper gastrointestinal, bleeding associated with portal hypertension.
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Affiliation(s)
- S Malki
- Department of Gastroenterology, The Canberra Hospital, Woden, ACT, Australia
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Chen WC, Hou MC, Lin HC, Chang FY, Lee SD. An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature. Am J Gastroenterol 2000; 95:540-2. [PMID: 10685765 DOI: 10.1111/j.1572-0241.2000.01782.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report a 64-yr-old patient with liver cirrhosis and bleeding esophageal varices that were obliterated by repeated endoscopic sclerotherapy. Eleven years later, he developed a massive, life-threatening rectosigmoid variceal hemorrhage. An endoscopic injection with N-butyl-2-cyanoacrylate (Histoacryl), performed over the rectosigmoid varices, achieved temporary hemostasis. The etiology, prevalence, relationship with portal hypertension, diagnosis, and treatment of colorectal varices are discussed.
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Affiliation(s)
- W C Chen
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan
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Abstract
Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.
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Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195, USA
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35
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Balzer C, Lotterer E, Kleber G, Fleig WE. Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy. Gastroenterology 1998; 115:167-72. [PMID: 9649472 DOI: 10.1016/s0016-5085(98)70378-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal-hypertensive colopathy has attracted interest in recent years because such lesions can cause life-threatening hemorrhage. In contrast to upper gastrointestinal bleeding from varices, there is no established therapy for bleeding from angiodysplasia-like lesions. This case report describes the first successful use of transjugular intrahepatic portosystemic shunt (TIPS) for long-term control of bleeding from angiodysplasia-like colonic lesions in a patient with cirrhosis caused by chronic hepatitis B infection. During an 18-month course after TIPS, angiodysplasia-like lesions disappeared without any further evidence of recurrent hematochezia. TIPS may be helpful as second-line treatment in patients with recurrent portal-hypertensive bleeding from colonic angiodysplasia-like lesions who do not tolerate or are unresponsive to treatment with beta-adrenergic blockers.
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Affiliation(s)
- C Balzer
- First Department of Medicine, Martin-Luther-University Halle-Wittenberg, Germany
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38
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Fitzgerald JB, Chalmers N, Abbott G, Lee SH, Warnes TW, Youngs GR, Wardle TD. The use of TIPS to control bleeding caput medusae. Br J Radiol 1998; 71:558-60. [PMID: 9691903 DOI: 10.1259/bjr.71.845.9691903] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Two patients with cirrhosis and portal hypertension had persistent bleeding from caput medusae and ascites. Transjugular intrahepatic portosystemic shunt (TIPS) resulted in regression of the caput medusae and ascites in both cases.
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Affiliation(s)
- J B Fitzgerald
- Department of Clinical Radiology, Manchester Royal Infirmary, UK
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